title: Incremental cost effectiveness of pharmacist-managed erythropoiesis-stimulating agent clinics for non-dialysis-dependent chronic kidney disease patients.
abstract: BACKGROUND
  Pharmacists successfully manage patients with anemia and chronic kidney disease (CKD), but the cost effectiveness of these programs is unknown.
  
  
  OBJECTIVE
  To compare the cost effectiveness of pharmacist-managed erythropoiesis-stimulating agent (ESA) clinics with that of usual care in patients with non-dialysis-dependent (NDD)-CKD.
  
  
  METHODS
  A Markov model was used to estimate the incremental cost effectiveness of pharmacist-managed ESA clinics compared with usual care in outpatient veterans receiving ESAs for NDD-CKD in 2009. The analysis was conducted from a US Veterans Health Administration perspective with a 5-year time horizon, and the year of valuation for cost results was 2012. The effect of parameter uncertainty was explored in one-way and probabilistic sensitivity analyses.
  
  
  RESULTS
  In the deterministic base case analysis, costs and effectiveness per patient over 5 years were US$13,412 and 2.096 quality-adjusted life-years (QALYs) in the pharmacist-managed ESA clinics and US$16,173 and 2.093 QALYs in usual care; ESA clinics dominated usual care. In one-way sensitivity analyses, ESA clinics no longer dominated if their patients' probability of being in the target hemoglobin range fell to 52 % (base case 71 %) or if the mean cost/patient/month of epoetin or darbepoetin in ESA clinics increased to approximately US$382 (base case US$226) or US$477 (base case US$268), respectively. When all parameters were varied simultaneously in a probabilistic sensitivity analysis, ESA clinics were favored ≥80 % of the time at willingness-to-pay thresholds of US$0-$100,000 per QALY gained.
  
  
  CONCLUSIONS
  Pharmacist-managed ESA clinics were less costly and more effective than usual care in patients receiving ESAs for anemia and NDD-CKD. Results were robust to variation and support the use of pharmacist-managed ESA clinics.
authors.affiliation: VA Center for Medication Safety, Hines, IL, USA, sherrie.aspinall@va.gov.
authors.forename: Sherrie L
authors.initials: SL
authors.lastname: Aspinall
authors.forename: Kenneth J
authors.initials: KJ
authors.lastname: Smith
authors.forename: Chester B
authors.initials: CB
authors.lastname: Good
authors.forename: Xinhua
authors.initials: X
authors.lastname: Zhao
authors.forename: Roslyn A
authors.initials: RA
authors.lastname: Stone
authors.forename: Ivy Q
authors.initials: IQ
authors.lastname: Tonnu-Mihara
authors.forename: Francesca E
authors.initials: FE
authors.lastname: Cunningham
mesh_terms: D000368:Aged; D000554:Ambulatory Care Facilities / Q000191:economics*; D003362:Cost-Benefit Analysis; D017850:Economics, Pharmaceutical; D005260:Female; D006397:Hematinics / Q000191:economics* / Q000627:therapeutic use*; D006787:Hospitals, Veterans; D006801:Humans; D007676:Kidney Failure, Chronic / Q000188:drug therapy* / Q000191:economics*; D007677:Kidney Function Tests; D008297:Male; D008390:Markov Chains; D010595:Pharmacists; D019057:Quality-Adjusted Life Years; D016896:Treatment Outcome; D014481:United States
chemical_list: D006397:Hematinics